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Background: The aim of this case-control study was to evaluate the outcome of isolated coronary artery bypass grafting (CABG) when using a short (median, 2 days) preoperative pause in home warfarin treatment. Methods: A consecutive series of 162 patients on long-term warfarin treatment (median international normalized ratio at the time of operation, 1.9) who underwent isolated CABG was compared with a matched control group of 162 patients with no oral anticoagulation. Results: The operative risk of warfarin-treated patients was higher (p = 0.001) than in the control patients. The in-hospital mortality was comparable in the warfarin and control groups (3.7% versus 2.5%; p = 0.52), and there were no significant differences in the postoperative blood loss (818 versus 758 mL), transfused red blood cells (2.1 versus 1.8 units), or reoperations owing to bleeding (5.6% versus 7.4%) between the groups. The warfarin group received more (p < 0.0001) fresh-frozen plasma (1.9 versus 0.5 units), needed longer treatment in the intensive care unit (4.1 versus 2.9 days; p < 0.0001), and tended to have an increased risk of postoperative stroke (4.9% versus 1.2%; p = 0.10). A CHADS2 score greater than 2, but not the international normalized ratio level, was associated with an increased risk of stroke when adjusted for other important comorbidities. Comparable results were observed also in 107 propensity-matched pairs. Conclusions: The risk of bleeding complications after isolated CABG is not increased when using a short preoperative pause in warfarin treatment. Better preventive strategies for stroke are needed, especially in patients with a high CHADS2 score. [Copyright &y& Elsevier]

Background: Rapid identification of a proximal occlusion site of a major coronary artery is of paramount importance in the care of myocardial infarction (MI). It is increasingly recognized that routine electrocardiogram (ECG) can be used for that purpose, provided that expert interpretation is available. Computer-based signal analysis has potential to enhance early ECG interpretation but its performance must be validated against manual algorithms. We therefore set out to develop a computer-assisted model to detect proximal occlusion of the left anterior descending coronary artery (LAD) in patients with suspected acute coronary syndrome (ACS).Methods: Based on manual anatomical interpretation of the ECG, obtained from 216 consecutive patients who were admitted due to suspected ACS, an automatic computerized ECG model to detect LAD occlusion was constructed. Agreement between manual evaluation of the ECG by two cardiologists and a computerized ECG algorithm to detect occlusion of the LAD and the site of occlusion was determined.Results: Using an expert electrocardiographer's anatomical interpretation as the gold standard, the computer model recognized patients fulfilling ECG criteria for any occlusion of the LAD with a specificity of 99% and a sensitivity of 67% (kappa= 0.71). However, proximal LAD occlusion was detected with 100% specificity and 86% sensitivity (kappa= 0.72). The computer program detected a distal occlusion in the LAD with a specificity of 99% and a sensitivity of 40% (kappa= 0.72).Conclusions: Computerized anatomical interpretation of the ECG is feasible and allows detection of a proximal LAD occlusion with excellent accuracy. [ABSTRACT FROM AUTHOR]

The purpose of this study was to investigate the applicability of computerized electrocardiogram interpretation in classifying patients with suspected acute myocardial infarction. Computerized acquisition and analysis of the 12-lead electrocardiogram can increase the consistency and reduce the workload of patient classification. The serial electrocardiograms of 311 consecutive patients with suspected myocardial infarction were studied and a new computerized myocardial infarction (CMI) electrocardiographic classification was developed and compared with one commercially available and two manual codes. Statistically, there was almost no correlation between the four ECG codes. Compared with the WHO enzymatic criteria, the sensitivity of the CMI code toward detecting definite and possible infarction was 69.2% and 29.8% with a specificity of 62.1% and 79.7%, respectively. In subjects without previous infarction (n = 214) the sensitivity of the CMI code for definite enzymatic infarction was 71.9% and specificity 77.6%. Substituting the CMI for the Minnesota code had no effect on patient classification by the WHO MONICA criteria in 78% of patients with first infarction. Judged by cardiac macromolecular leakage, all electrocardiographic classifications of possible infarction were poorly correlated with myocardial tissue injury. We have developed a new computerized coding system to detect electrocardiographic myocardial infarction. The structure of the code allows interactive redefinition of criteria to meet user-defined needs. However, because of the weak relationship between electrocardiographic and biochemical criteria of myocardial injury, the role of ECG in the diagnostic classification of acute ischemic syndromes should be re-evaluated. [ABSTRACT FROM AUTHOR]

The automated ST-elevation score at admission and maximal QRS score during hospitalization provide good estimates of biochemical injury size during the course of first myocardial infarction. Being easily computerized, such scores could be used routinely to monitor the effect of injury-limiting therapy. [ABSTRACT FROM AUTHOR]

Background: After percutaneous coronary intervention (PCI), patients at high bleeding risk (HBR) according to The Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria have increased risk for ischemic complications. The underlying cause is not well documented. The aim of this study was to assess the ischemic risk among ST-elevation myocardial infarction (STEMI) patients classified as HBR according to the ARC-HBR and to identify individual risk factors., Methods: Consecutive STEMI patients treated with primary PCI in a Finnish tertiary hospital between 2016 and 2022 were identified using a database search. Data was collected by reviewing electronic patient records. Bleeding risk was assessed according to the ARC-HBR criteria. The primary endpoint was 1-year major adverse cardiovascular or cerebrovascular event (MACCE)., Results: In total, 1367 STEMI patients were included. Cumulative incidence of MACCE was 19.5 % among HBR and 6.32 % among non-HBR. From the ARC-HBR criteria, multivariable competing risk analysis identified use of non-steroidal anti-inflammatory drugs or steroids and active malignancy as risk factors for MACCE. Diabetes and left ventricular ejection fraction <35 % were MACCE predictors and both were more prevalent among HBR patients. Dual antiplatelet therapy duration of ≥3 months significantly reduced risk of MACCE and was less prevalent among HBR., Conclusions: The higher observed ischemic risk among HBR patients might not be explained by bleeding risk status itself but rather with some of its components and other underlying comorbidities and management strategies. These findings may be useful when evaluating the balance of ischemic and bleeding risks based on patient-specific risk factors., Competing Interests: Declaration of competing interest Henri Kesti received research grants for the present study (listed in Funding section). Pekka Porela is the current Secretary in The Finnish Cardiac Society. Other authors have no conflicts of interest to declare., (Copyright © 2025 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: In this study in a tertiary care hospital, we examined the characteristics of the different microbial etiologies of infective endocarditis (IE) and the factors associated with embolic events., Materials and Methods: We included patients (aged ≥18 years) hospitalized for IE in Turku University Hospital in Finland between 2004-2017. Patient data were derived retrospectively from the mandatory database and patient record system., Results: Among 342 IE cases in 321 patients, Staphylococcus aureus was isolated in 33.9%, viridans group streptococci in 18.3% and enterococci in 8.8% of the cases. Patients with enterococcal IE had more often a prosthetic valve ( p  < 0.001), recent major healthcare procedure or hospital admission ( p  < 0.001) and heart failure during admission ( p  = 0.006) than the patients with other etiologies. Viridans group streptococci and enterococci vs. S. aureus were associated with a lower rate (OR 0.34, p  = 0.007 and OR 0.20, p  = 0.006, respectively) and IE of the multiple valves vs. aortic valve with a higher rate (OR 2.30, p  = 0.043) of all embolic events but not cerebral embolisms when analyzed separately. Both all embolic events and cerebral embolisms were strongly associated with the occurrence of an echocardiography-disclosed vegetation (OR 3.31, p  = 0.004 and OR 2.73, p  = 0.019, respectively)., Conclusions: Our study suggests that enterococcal IE is often associated with a previous healthcare procedure or hospital admission and heart failure. Staphylococcus aureus etiology and IE of the multiple valves are associated with a higher rate of all embolic events but not cerebral embolisms. Echocardiography-disclosed vegetation is associated with a higher occurrence of embolisms.

Background and Aims: The Academic Research Consortium for High Bleeding Risk Criteria (ARC-HBR) are recommended by guidelines for bleeding risk assessment in ST-elevation myocardial infarction (STEMI). The aim of this study was to identify possible other risk factors and adjust the original ARC-HBR criteria for confounders., Methods: All consecutive STEMI patients managed in a Finnish tertiary hospital between 2016-2022 were identified using a database search. Data collection was done by reviewing electronic patient records. Bleeding risk was assessed according to the ARC-HBR criteria. The primary endpoint was non-access site bleeding academic research consortium (BARC) type 3 or 5 bleeding during 1-year follow-up., Results: A total of 1548 STEMI patients were analysed. HBR criteria was fulfilled in 661 (42.7%). Multivariable competing risk analysis identified only 4 individual ARC-HBR criteria as independent risk factors for bleeding. Smoking status was identified as a novel bleeding risk factor. Current and former smokers had increased bleeding risk compared with never smokers (hazard ratio [HR] 3.01, 95% confidence interval [CI] 1.62-5.61 and HR 1.99, CI 1.19-3.34). In those not meeting any ARC-HBR criteria, cumulative BARC 3 or 5 incidence of current smoking was 3.40% and intracranial haemorrhage (ICH) 1.36%. Thus, exceeding ARC-HBR definition for a major criterion. In the non-HBR group the prevalence of current smoking was 40.4% (n = 358)., Conclusions: Current and former smoking predicts major bleeding complications after STEMI. Current smoking is highly prevalent among those classified as non-HBR according to the ARC-HBR criteria., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

High bleeding risk (HBR) is commonly encountered among patients with acute coronary syndrome (ACS), and bleeding complications are associated with worse prognosis. Data on bleeding events of patients with ACS are based almost exclusively on percutaneous coronary intervention registries. Enrolling only patients suitable for invasive procedures might have skewed the observed bleeding incidence. We sought to investigate bleeding incidence in unselected patients with ACS. Patients were retrospectively enrolled between January and June 2019 from the emergency department of a tertiary hospital. All consecutive hospitalized adults with suspected non-ST-segment elevation myocardial infarction were included. Data was gathered by a database search and verified using electronic patient records. Bleeding risk was assessed according to the Academic Research Consortium for High Bleeding Risk (ARC-HBR) definition. The primary end point was a composite of post- discharge Bleeding Academic Research Consortium type 2, 3, and 5 bleeding during 1-year follow-up. Of the 209 included patients, 15 (7.2%) suffered a bleeding event. There were more bleeding events among dual antiplatelet therapy (DAPT) users as compared with those without DAPT (10.7% vs 3.1%, p = 0.033). Among HBR patients, 6.1% and in non-HBR patients 8.1% suffered a bleeding event (p = 0.579). Notably, major bleeding (Bleeding Academic Research Consortium type 3) incidence was highest in patients <65 years and without DAPT use. In conclusion, unselected suspected non-ST-segment elevation myocardial infarction patients aged <65 years had surprisingly high bleeding incidence, regardless of ARC-HBR status or DAPT use., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

In recent years, guidelines for the management of acute coronary syndromes (ACS) have placed more emphasis on identifying patients at high bleeding risk (HBR). We set out to investigate the prevalence of HBR patients according to the Academic Research Consortium for High Bleeding Risk (ARC-HBR) criteria in hospitalized patients with suspected non-ST-segment elevation myocardial infarction (NSTEMI). Consecutive patients were retrospectively enrolled between January and June 2019 from the emergency department (ED) of a tertiary hospital. The discharge diagnosis and baseline data were manually collected using electronic patient records and database searches. Patients with non-cardiac diagnoses were excluded. Overall, 212 patients were included in the study. A total of 146 (68.9%) patients were diagnosed with NSTEMI (Type 1), 47 (22.2%) with unstable angina pectoris (UAP) and 19 (9.0%) with "other." HBR was detected in 47.6% ( n = 101) of all patients. Common criteria for HBR among ACS patients were age (40.4%), chronic kidney disease (33.7%), and the use of oral anticoagulation medicines (20.2%). In conclusion, nearly half of the patients hospitalized for ACS fulfilled HBR criteria. According to contemporary guidelines, the management of HBR patients differs from that of non-HBR patients, and thus, a more comprehensive screening for HBR may be considered in clinical practice.

Patients with atrial fibrillation (AF) presenting to the emergency department (ED) often have elevated cardiac troponin T (TnT) levels without evidence of type 1 myocardial infarction. We sought to explore the causes and significance of minor TnT elevations in patients with AF at the ED. All patients with AF admitted to the ED of Turku University Hospital between 1 March, 2013 and 11 April, 2016, and at least two TnT measurements, were screened. Overall, 2911 patients with a maximum TnT of 100 ng/L during hospitalization were analyzed. TnT was between 15 and 100 ng/L in 2116 patients. The most common primary discharge diagnoses in this group were AF (18.1%), infection (18.3%), ischemic stroke/transient ischemic attack (10.7%), and heart failure (5.0%). Acute coronary syndrome (ACS) was equally uncommon both in patients with normal TnT and elevated TnT (4.4% vs. 4.5%). Age ≥75 years, low estimated glomerular filtration rate (eGFR), high C-reactive protein (CRP), and hemoglobin <10.0 g/dL, were the most important predictors of elevated TnT. Importantly, TnT elevation was a very frequent (>93%) finding in elderly (≥75 years) AF patients with either low eGFR or high CRP. In conclusion, minor TnT elevations carry limited diagnostic value in elderly AF patients with comorbidities.

Objectives: Infective endocarditis (IE) is a life-threatening disease associated with significant mortality. We studied recent temporal trends and age and sex differences in the occurrence and short-term mortality of IE., Design: Population based retrospective cohort study., Setting: Data of IE hospital admissions in patients aged ≥18 years in Finland during 2005-2014 and 30-day all-cause mortality data were retrospectively collected from mandatory nationwide registries from 38 hospitals., Outcomes: Trends and age and sex differences in occurrence. Thirty-day mortality., Results: There were 2611 cases of IE during the study period (68.2% men, mean age 60 years). Female patients were significantly older than males (62.0 vs 59.0 years, p=0.0004). Total standardised annual incidence rate of IE admission was 6.33/100 000 person-years. Men had significantly higher risk of IE compared with women (9.5 vs 3.7/100 000; incidence rate ratios [IRR] 2.49; p<0.0001) and difference was most prominent at age 40-59 years (IRR 4.49; p<0.0001). Incidence rate varied from 5.7/100 000 in 2005 to 7.1/100 000 in 2012 with estimated average 2.1% increase per year (p=0.036) and similar trends in both sexes. Significant increasing trend was observed in patients aged 18-29 years and 30-39 years (estimated annual increase 7.6% and 7.2%, p=0.002) and borderline in patients aged 40-49 years (annual increase 3.8%, p=0.08). In older population, IE incidence rate remained stable. The overall 30-day mortality after IE admission was 11.3%. Mortality was similar between sexes, increased with ageing, and remained similar during the study period., Conclusions: Occurrence of IE is increasing in young adults in Finland. Men, especially middle-aged, are at higher risk for IE compared with women. Thirty-day mortality has remained stable at 11%, increased with ageing, and was similar between sexes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

This guideline covers coronary heart disease symptoms, diagnosis and treatment. Stable coronary heart disease refers to a disease in, which patients have stable symptoms and evidence of ischemia or significant stenosis of coronary artery. Diagnosis is based on medical history and exercise test, which is the primary diagnostic test. Coronary angiography is in selected cases necessary to confirm the diagnosis and assess invasive treatment. Pharmacotherapy aims to improve the survival of the patient, relieve symptoms and improve quality of life. The guideline also deals with invasive treatment either with PCI or CABG.

Background: Cardiac troponin-specific autoantibodies (cTnAAb) can interfere with the measurement of cardiac troponin I (cTnI) by immunoassays used for the diagnosis of myocardial infarction (MI). Here, an improved version of a previous autoantibody assay was validated and used to evaluate the cTnAAb prevalence in a cohort of consecutive chest pain patients presenting to an emergency department., Methods: Admission samples from 510 patients with suspected MI were analyzed in parallel with two sandwich-type cTnAAb assays based on different cTnI epitopes used to capture cardiac troponin-bound cTnAAbs., Results: Sample-specific backgrounds were lower for the new assay than for the old assay (median 1225 vs. 2693 counts, p<0.001). Net signals of cTnAAb-positive samples were higher for the new assay than for the old assay (median 5076 vs. 3921 counts, p<0.001). Of all patients, 9.2% were cTnAAb-positive for the new assay and 7.3% for the old assay (p=0.013). Previous cardiac problems were not associated with cTnAAb status and cTnAAb status did not correlate with the 12-month outcome., Conclusions: With our new and more sensitive autoantibody assay, approximately one out of ten patients who presented to the initial cardiac triage had detectable amounts of cTnAAbs in the circulation. Because these cTnAAbs can interfere with state-of-the-art cTnI assays, their high prevalence should be acknowledged by clinical chemists, physicians, and kit manufacturers.

Background: The safety of drug-eluting stents (DES) in patients on long-term warfarin treatment has been questioned due to high risk of bleeding complications during prolonged triple (aspirin, clopidogrel, and warfarin) antithrombotic therapy., Methods: We analysed the long-term outcome of 415 consecutive warfarin-treated patients who underwent DES (n = 191) or bare-metal (n = 224) stenting in six hospitals., Results: The mean duration of triple therapy was longer (4.2 ± 3.1 versus 2.1 ± 1.8 months; P < 0.001) in the DES group. The incidence of major adverse cardiovascular and cerebrovascular events was comparable in the DES and bare-metal groups (39.8% versus 42.4%; P = 0.59) during a median follow-up of 3.5 years. Similarly, major bleeding events occurred equally often in both study groups (14.7% versus 12.9%). Six patients in the DES group and seven patients in the bare-metal group suffered stent thrombosis (3.1% versus 3.1%). In the propensity score analyses of 101 matched pairs, the outcome was similar in the two groups., Conclusion: Selective use of DES with a short triple therapy seems to be safe in patients with warfarin therapy. The prognosis of this fragile patient population is quite poor, and major bleeding events are common irrespective of stent type.

Objectives: To investigate the predictive value of cystatin C among patients diagnosed with non-ST-elevation acute coronary syndrome (nSTE-ACS)., Design and Methods: Admission serum samples from 245 nSTE-ACS patients were measured with a novel cystatin C immunoassay based on a dry-reagent, double monoclonal design. Creatinine concentrations, estimated glomerular filtration rates (eGFR) and one-year follow-up data were available for these patients., Results: During the follow-up period, 34 (14%) of patients had myocardial infarction (MI) and 25 (11%) died. Increased serum cystatin C was an independent predictor of all-cause mortality and combined events (all-cause mortality and MI) after adjustment to non-biomarker baseline factors, hazard ratio (HR) 2.19 (per increase of 1 tertile; 95% Cl 1.28-3.78, p=0.0046) and 1.75 (1.22-2.51, p=0.0024), respectively. Corresponding values for eGFR were 2.56 (1.43-4.59, p=0.0016) and 1.76 (1.23-2.53, p=0.0022), respectively. Creatinine was not an independent predictor of endpoints (p>0.05)., Conclusions: Cystatin C was associated with an increased risk of death and combined events in patients with nSTE-ACS., (Copyright © 2012 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved.)

Background: Deviation of the PR segment is a common but often ignored ECG finding in acute myopericarditis, but seems to be rare in the acute phase of ST elevation myocardial infarction (STEMI). Since rapid bedside differential diagnosis of acute myopericarditis and STEMI is essential, we decided to assess the diagnostic power of PR depressions in patients presenting with ST elevations in the emergency room., Methods: Thirty-four consecutive patients with acute myopericarditis and 46 STEMI patients presenting with ST elevations fulfilling the criteria for STEMI were included. The first ECG recorded in the emergency room was analyzed with a focus on the PR segment. The diagnoses of myopericarditis and STEMI were ascertained with clinical follow-up together with rise in troponin levels, and in the STEMI patients also with coronary angiography., Results: In myopericarditis, the most common location for PR depression was lead II (55.9%), while this ECG finding least likely appeared in lead aVL (2.9%). PR depression in any lead had a high sensitivity (88.2%), but fairly low specificity (78.3%) for myopericarditis. The combination of PR depressions in both precordial and limb leads had the most favorable predictive power to differentiate myopericarditis from STEMI (positive 96.7% and negative power 90%)., Conclusions: Our present observations show that PR segment analysis is a powerful tool in the differential diagnosis of myopericarditis and STEMI. This simple information should be added to the diagnostic workup of patients presenting with ST elevations., (© 2012, Wiley Periodicals, Inc.)

Introduction: Therapeutic (international normalized ratio, INR 2.0-3.5) oral anticoagulation (TOAC) is assumed to increase perioperative bleeding complications and a standard recommendation is to discontinue warfarin before coronary bypass grafting (CABG)., Materials and Methods: To assess the safety of TOAC we retrospectively analyzed consecutive patients (n=270) with long-term warfarin therapy referred for CABG in two centers where TOAC strategy is employed. The main in-hospital outcomes of interest were death, stroke, acute myocardial infarction, new onset renal failure, resternotomy, and their composite. In the TOAC group of 103 patients CABG was performed during therapeutic oral anticoagulation and in the control group (81 patients) preoperative INR was lowered to a subtherapeutic (≤1.5) level., Results: The patients in TOAC group were more often operated on an emergency basis (p=0.02) and their EuroSCORE was higher (p=0.02). There were no significant differences in the major outcome events or their composite (17.5 vs. 11.1%, p=0.30) between the groups. Patients in the TOAC group had more postoperative blood loss (941±615 vs. 754±610 ml, p<0.01) and received more fresh frozen plasma (2.8±3.0 vs. 1.3±2.4 units, p<0.001), but transfused red blood cells (2.1±2.8 vs. 2.1±3.4 units) were comparable in the groups. Preoperative clopidogrel (OR 4.8, 95% CI 1.4-16.2, p=0.01) and enoxaparin therapy (OR 2.6, 95% CI 1.1-6.5, p=0.04) were the only significant independent predictors for any major adverse event., Conclusions: Our study suggests that CABG is a safe procedure during TOAC with no excess bleeding or major complications. Prospective trials are needed to confirm this observation., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Intravenous low molecular weight (LMWH) and unfractionated heparin (UFH) increase the circulating concentrations of pregnancy-associated plasma protein A (PAPP-A), a novel cardiac risk marker, in haemodialysis and coronary angiography patients., Methods: To further investigate the mechanisms of heparin effects, free PAPP-A was analysed in serial serum samples collected during haemodialysis (intravenous LMWH), carotid endarterectomy or abdominal aortic aneurysm surgery (intravenous UFH), treatment at intensive care unit (subcutaneous LMWH), and coronary angiography (intravenous bivalirudin). PAPP-A was extracted from plaque tissue samples of endarterectomy and aneurysm patients. The interaction between heparin products and free PAPP-A was studied with gel filtration., Results: After intravenous UFH and LMWH free PAPP-A increased significantly but bivalirudin had no effect. After LMWH bolus in haemodialysis patients 85% of free PAPP-A was cleared with a half-life of 13.1 min and the rest with a half-life of 96.6 min. Subcutaneous LMWH led to lower and slower free PAPP-A elevation. PAPP-A extracted from plaque tissues was in free form and extraction was strongly enhanced by LMWH. Heparin products increased the molecular size of free PAPP-A., Conclusions: The heparin-induced PAPP-A elevation is seen in various patients and should be taken into account when PAPP-A is studied as a biomarker., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Long-term oral anticoagulation (OAC) prevents recurrent thrombosis, pulmonary embolism, and stroke, but it also increases bleeding risk. An outpatient bleeding risk index (OBRI) may help to identify patients at high risk of bleeding complications. The aim of this study was to evaluate the predictive value of OBRI in patients with OAC undergoing percutaneous coronary intervention (PCI). In addition, we analyzed the impact of OBRI on treatment choices in this patient group. Four hundred twenty-one patients with OAC underwent PCI at 6 centers in Finland. Complete follow-up was achieved in all patients (median 1,276 days). Sixty-four patients (15%) had a low bleeding risk (OBRI 0), 319 patients (76%) moderate bleeding risk (OBRI 1 to 2), and 38 (9%) high bleeding risk (OBRI 3 to 4). OBRI had no significant effect on periprocedural or long-term antithrombotic medications, choice of access site, or stent type. During follow-up, the incidence of major bleeding increased (p = 0.02) progressively with higher OBRI category (6.3%, 14.1%, and 26.3%, respectively). Similarly, mortality was highest in patients with high OBRI (14.1%, 20.7%, and 39.5%, p = 0.009, respectively), but rates of major adverse cardiovascular and cerebrovascular events were comparable in the OBRI categories. In conclusion, bleeding risk seems not to modify periprocedural or long-term treatment choices in patients after PCI on home warfarin. In contrast, patients with high OBRI often have major bleeding episodes and this simple index seems to be suitable for risk evaluation in this patient group., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

Background: The free fraction of pregnancy-associated plasma protein A (FPAPP-A) was found to be the PAPP-A form released to the circulation in acute coronary syndrome (ACS). We estimated the prognostic value of FPAPP-A vs total PAPP-A (TPAPP-A) concentrations in forecasting death and nonfatal myocardial infarction (combined endpoint) in patients with non-ST-elevation ACS., Methods: We recruited 267 patients hospitalized for symptoms consistent with non-ST-elevation ACS and followed them for 12 months. FPAPP-A, TPAPP-A, C-reactive protein (CRP), and cardiac troponin I (cTnI) were measured at admission; cTnI was also measured at 6-12 h and 24 h. Because of the recently shown interaction between PAPP-A and heparin, we excluded patients treated with any heparin preparations before the admission blood sampling., Results: During the follow-up, 57 (21.3%) patients met the endpoint (22 deaths and 35 nonfatal myocardial infarctions). According to FPAPP-A (<1.27, 1.27-1.74, >1.74 mIU/L) and TPAPP-A (<1.98, 1.98-2.99, >2.99 mIU/L) tertiles, this endpoint was met by 12 (13.5%), 18 (20.2%), 27 (30.3%) (P = 0.02), and 17 (19.1%), 17 (19.1%), 23 (25.8%) (P = 0.54) patients, respectively. After adjusting for age, sex, diabetes, previous myocardial infarction, and ischemic electrocardiogram (ECG) findings, FPAPP-A >1.74 mIU/L [risk ratio (RR) 2.0; 95% CI 1.0-4.1, P = 0.053), increased cTnI, and CRP >/=2.0 mg/L were independent predictors of an endpoint. The prognostic performance of TPAPP-A was inferior to that of FPAPP-A., Conclusions: FPAPP-A seems to be superior as a prognostic marker compared to TPAPP-A, giving independent and additive prognostic information when measured at the time of admission in patients hospitalized for non-ST-elevation ACS.

Background: Cardiac troponin elevations are associated not only with acute coronary syndromes (ACS) but also with multiple other cardiac and non-cardiac conditions., Study Objectives: To investigate the etiology and clinical significance of cardiac troponin I elevations in an unselected Emergency Department (ED) patient cohort., Methods: The study population consisted of 991 consecutive troponin-positive patients admitted to the ED of a university hospital with ACS as the presumptive diagnosis. Cardiac troponin I was measured on admission and a follow-up sample was obtained at 6-12 h. Clinical diagnosis was ascertained retrospectively using all the available information including electrocardiogram, clinical data, laboratory tests, and available coronary angiograms., Results: At admission, 805 (81.2%) patients were already troponin positive; of these, the troponin elevation was related to myocardial infarction (MI) in 654 (81.2%) patients. Finally, 83.0% of the troponin elevations were due to MI, 7.9% were related to other cardiac causes, and 9.1% to non-cardiac diseases. The leading non-cardiac causes were pulmonary embolism, renal failure, pneumonia, and sepsis. Non-cardiac patients with elevated troponin I at admission showed significantly higher in-hospital mortality (26.7% vs. 13.4%, p = 0.002) compared to cardiac patients., Conclusion: Elevated troponin levels for reasons other than MI are common in the ED and are a marker of poor in-hospital prognosis., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Pregnancy-associated plasma protein A (PAPP-A) has been suggested as a useful diagnostic and prognostic marker in acute coronary syndromes. Because low molecular weight heparin (LMWH) and unfractionated heparin (UFH) are commonly used in these cases, we analyzed the effects of intravenous administration of these heparins on serum PAPP-A concentrations., Methods: Serum concentrations of total and free PAPP-A were analyzed in 14 patients on chronic hemodialysis and in 10 coronary angiography patients. Ten of the dialysis patients received standard LMWH anticoagulation at the start of dialysis, and 4 were treated with a heparin-free method. Two of the patients on heparin-free hemodialysis received a reduced LMWH bolus 2 h after the start of dialysis. All angiography patients received UFH at the start of the procedure, and 1 patient received 2 extra boluses of UFH. Serum PAPP-A concentrations were analyzed before and during the dialysis session and during the coronary angiography examination., Results: A rapid increase in total PAPP-A (median, 25-fold) was seen in all patients within 5 min of administration for both LMWH and UFH boluses. This response was due to an increase in free PAPP-A in the serum. PAPP-A did not increase significantly in the patients who underwent heparin-free hemodialysis. Repeated heparin boluses induced a new PAPP-A release. In vitro addition of heparins to samples of whole blood did not increase PAPP-A concentrations., Conclusions: Intravenous administration of heparin induces an intense and rapid increase in free PAPP-A in the serum. We recommend that this effect be considered when PAPP-A is assessed as a biomarker in acute coronary syndromes.

Background: We compared the early diagnostic and prognostic performance of a highly sensitive cardiac troponin I (cTnI) assay with heart-type fatty acid binding protein (H-FABP), in the early hours of acute coronary syndrome., Methods: Serum samples of 293 patients were studied using the Abbott Architect cTnI assay and the H-FABP assay. Special attention was paid to the diagnostic and prognostic value of admission blood samples taken <24 h after symptom onset. The prognostic endpoint was total mortality and reinfarction at 6 months., Results: To detect forthcoming myocardial injury, admission samples gave receiver operating curve (ROC) areas (AUC) of 0.908 for cTnI and 0.855 for H-FABP (p=0.068) when the delay from symptom onset was <6 h (60.4% of all patients). When the delay was 6-24 h, the corresponding AUC values were 0.995 for cTnI and 0.849 for H-FABP (p=0.002). In multivariate analysis cTnI but not H-FABP predicted adverse events in all 293 patients (RR 3.02, 95% CI 1.62-5.63) and in those with delays <6 h (RR 2.92, 95% CI 1.47-5.81)., Conclusion: In the era of highly sensitive cTnI assays, H-FABP appears to give no additional information even in patients who present within the first 6 h after acute MI.

Long-term warfarin therapy is assumed to increase bleeding and access site complications after coronary angiography and it is often recommended to postpone invasive procedures to reach international normalized ratio (INR) levels <1.8. To assess the safety and feasibility of diagnostic coronary angiography during uninterrupted warfarin therapy, we retrospectively analyzed all consecutive patients (n = 258) on warfarin therapy referred for diagnostic coronary angiography in 2 centers with long experience in uninterrupted warfarin therapy during coronary angiography and in 1 center with a policy of preprocedural warfarin pause. An age- and gender-matched control group (n = 258) with similar disease presentation (unstable or stable symptoms) was collected from each center. Radial access was used in 56% of patients in the warfarin group and in 60% of controls (p = 0.21). There was no difference in access site and bleeding complications (1.9% vs 1.6%) or major adverse cardiovascular and cerebrovascular events (0.4% vs 0.8%) between the warfarin group and their controls. Warfarin was interrupted in 80 patients (31%), and bridging therapy was used in 24 of these patients (30%). INR levels were higher in the uninterrupted warfarin group (2.3 vs 1.9, p <0.001), but the incidence of access site complications was not higher (1.7%) than in patients (n = 80) with a warfarin pause (2.5%) or in patients with pause and bridging therapy (8.3%). Need for blood transfusions (n = 2) occurred only in patients with bridging therapy. Access site complications were more common in the 22 patients with supratherapeutic anticoagulation (INR >3) than in patients with therapeutic periprocedural INR (9.1% vs 1.5%, p <0.05). In conclusion, a simple strategy of performing coronary angiography during uninterrupted therapeutic warfarin anticoagulation is a tempting alternative to bridging therapy and is likely to lead to considerable cost savings.

Background: Elevated cardiac troponin (cTn) levels are relatively common in acute heart failure (AHF)., Aims: To evaluate the prevalence and prognostic significance of elevated cTnI and cTnT in AHF., Methods: FINN-AKVA is a prospective, multicenter study in AHF. In this analysis, 364 non-ACS patients with measurements of cTnI and cTnT taken on admission and 48 h thereafter were analyzed., Results: Of the 364 AHF patients, 51.1% had cTnI and 29.7% cTnT levels above the cut-off value. Six-month all-cause mortality was 18.7%. Both cTnI (OR 2.0, 95% CI 1.2-3.5, p=0.01) and cTnT (OR 2.6, 95% CI 1.5-4.4, p=0.0006) were associated with adverse outcome. The mortality risk was proportional to the magnitude of cTn release. On multivariable analysis, Cystatin C (OR 6.3, 95% CI 3.2-13, p<0.0001), logNT-proBNP (OR 1.4, 95% CI 1.0-1.8, p=0.03) and systolic blood pressure on admission (/10 mm Hg increase, OR 0.9, 95% CI 0.8-0.9, p=0.0004) were independent risk markers, whereas the troponins were not significantly associated with increased mortality., Conclusions: cTn elevations are frequent in AHF patients without ACS. cTnI is more often elevated than cTnT. Both cTnI and cTnT elevations are associated with increased mortality proportional to the degree elevation but they do not act as independent risk markers.

Background: Elevated circulating levels of pregnancy-associated plasma protein A (PAPP-A), a novel marker of atherosclerotic plaque instability, are associated with increased risk of future cardiac events in patients with acute coronary syndromes (ACS). However, little is known of the kinetics or clinical significance of circulating PAPP-A after plaque rupture in acute ST-elevation myocardial infarction (STEMI)., Aim: To evaluate the 48-hour release of pregnancy-associated plasma protein A (PAPP-A) and its association with 12-month outcome in patients with acute ST-elevation myocardial infarction (STEMI)., Methods: Sixty-two consecutive STEMI patients were included (40 men and 22 women, median age 67.5 years (range 34-84)), of whom 54 (87.1%) received reperfusion therapy. PAPP-A was measured at admission and 6-12, 24 and 48 hours thereafter. In 14 patients, samples were obtained also at 1, 2 and 4 hours., Results: There was an early peak of circulating PAPP-A during the first 12 hours from symptom onset, followed by rapid normalization. A second, late PAPP-A elevation was noticed in 20/62 patients (32.3%). Admission PAPP-A >10.0 mIU/L (highest tertile) was associated (P = 0.049) with increased 12-month risk of cardiovascular death or non-fatal myocardial infarction. Moreover, the combination of failed early reperfusion together with late PAPP-A elevation was strongly (7/13 versus 10/49 patients, P = 0.016) associated with adverse outcome. Admission PAPP-A did not correlate with admission C-reactive protein or cardiac troponin I., Conclusions: PAPP-A is elevated early in STEMI and then declines rapidly, a pattern consistent with release from the ruptured plaque. The variability of PAPP-A kinetics at 48 hours reflects the success of reperfusion. This study also shows that PAPP-A may have prognostic value in STEMI.

Accurate and rapid electrocardiographic interpretation is of crucial importance in acute coronary syndrome (ACS). Computerized electrocardiographic algorithms are often used in out-of-hospital settings. Their accuracy should be carefully validated in ACS, particularly in ST-elevation myocardial infarction. This study evaluated the comparative accuracy of lead-specific computer-based versus manual measurements of the J-point, ST-segment, and T-wave deviations in standard 12-lead electrocardiograms (ECGs) (excluding lead aVR). Sixty-nine consecutive patients with suspected ACS were included. The interobserver reliability in the determination of ST-segment deviation>or=0.2 mV in leads V2 and V3 was very good (kappa=0.94 and 0.93, respectively). Agreement between a cardiologist and the computer regarding ST elevation>or=0.2 mV in lead V2 was moderate (kappa=0.72) and in V3 was very good (kappa=0.85). For ST depression or elevation>or=0.05 mV in lead LIII, agreement was good and moderate (kappa=0.79 and 0.51, respectively). Bland-Altman analysis demonstrated clinically acceptable limits of agreement comparing measurements of the J point and the T wave, but clinically inadequate limits of agreement with respect to ST-segment deviation, between the electrocardiographer and the computer. The optimal cut-off points were 0.115 mV (sensitivity 89%, specificity 98%) for the computer program to detect ST elevation>or=0.2 mV and 0.045 mV (sensitivity 74%, specificity 99%) for revealing ST elevation>or=0.1 mV. It was found that automatically measured ST-segment deviations were smaller than those manually measured. In conclusion, a correction should be performed to obtain optimal results in the automated analysis of ECGs, because the results have important implications for clinical decision making.